special call in program looking back at woodstock, the 1969 cultural and musical phenomenon. historian david barber, author of the book the age of great dreams: america in the 1960s joins us to take your calls. >> drugs matter who takes those drugs, why the drugs have the effect did in the 60s and early 70s, it's something we're still wrestling with as scholars to understand . the technology of drugs and we've got some other people who had a long hard about this is imperative in understanding i think not just the vicinities but of the production and history, what drugs we use at a given. place an incredible ability to change the direction of a given society.>> thought in with david farber about the social movements ofthe 60s leading up to woodstock and his legacy woodstock , 50 years. sunday at 9 am eastern on washington journal. also live in american history tv on c-span3.

>> is erin bliss, he was with health and human services department and is the assistant inspector general for evaluation and inspections, welcome to the program. >> good morning. >> remind people of the role ofthe inspector general office is in comparison to hhs itself . >> our mission is to protect the integrity of health and human services programs such as medicare and the healthand well-being of the people that they serve . so we do oversight and enforcement of the programs of the health and human services department. >> you turn your attention recently to the topic of hospice. why is that, what are you looking to find out? >> the health and safety of medicare beneficiaries is one of our top priorities and help is a particularly vulnerable population so we looked at information about deficiencies being cited at health providers related to quality of care and patient harm . >> expand on that, what doyou find looking into this ?

>> a report shed light on how common it is to have as providers to be sided with some type of deficiency related to the quality of care they're providing and in some cases these were very serious deficiencies. we also uncovered gaps in patient protections. so we've issued a call to the medicare program run by the centers for medicare and medicaid services or cms to help fix these problems. >> let's start with the deficiencies, what were the worst-case scenario found when you were looking into this ? >> we did identify some worst-case scenarios where patients were seriously harmed by their care. so in one egregious example, hospice provider allowed maggot infested pastor around the patient feeding to and they needed to behospitalized . figure extreme case but anything should neverhappen .

>> so when it comes to the medicare system itself, remind people what they pay or at least what medicare pays for the hospices as far as dollars are concerned? >> in total in 2016, medicare paid about $16.7 billion for surveying approximately 1,000,000 and a half beneficiaries. the number of patients electing hospice care is growing and so likewise so are the dollars. hospice care is a program that patients can opt into when they are terminally ill and expected to have about six months or less left in their life . it's a decision to forgo regular curative treatments for their terminal illness and instead focus on services to provide pain relief, symptom relief, comfort and social and spiritualsupport for both the patients and their loved ones . >> 'sbook about the degrees of egregious conditions, washington post highlighted a couple others including some developing gangrenewhich

involved an application . sometimes and other things as well. why do these things , what's keeping from at least finding out aboutwere not taking care of these situations ? >> we've identified some gaps in the patient protection system . those are egregiousexample . we found about three in four hospice providers who were infected each year are identified to have some level of deficiency or not all that serious for about one in five they are serious deficiencies and then at about one percent of these extremely serious called immediate jeopardy deficiency and one of the problems we identified is that inflammation about these deficiencies and about serious complaints are investigated and substantiated is not made publicly available and in an easily accessible space so patients and their loved ones without a difficult time finding the public information and some of the informationis not public at

all . >> one third according toyour complaints filed againstthem when it comes off this providers, 300 considered poor performers, 20 percent had one or more serious deficiencies. if hospice is found in such a way , what is the remedy ? is there a punishment as well? >> survey agencies who do many of the inspections will work with hospice to try to correct the problem. but medicare is very limited in the enforcement tool that it has. right now the only action at the medicare program can take the hospicedoesn't correct his problems , it's to terminate them or not allow them to participate in medicare. there are no other tools. this is in contract issues that might arise for example in the nursing home where the medicare program as an array of tools to help remedy for performance. so we've recommended that the medicare program work with congress to get authority to

take a range of enforcement actions in these circumstances. >> we will continue talking with our guests, if you have questions about this report to look at the condition of hospices in the united states, 202-748-8000 if you live in the eastern and central time zones, 204 8000 in the central time zones, if you have experience with hospice care, 202 648-8000 two. go back to why as far as taking care of the issue, why is there such a difference between money that medicare since the nursing homes versus money sent to hospice care ? >> guest: i can't explain why the protections in hospice line behind our other types of care providers but we think it's time for that to change so we've made a number of recommendations to strengthen the protections for patients, the transparency of information,

enforcement tools availableto bring hospice care more on par with other types of care . >> what prompted this report in the first place? >> guest: oag has been assessing hospice care for more than a decade and we are focused and concerned about quality of care and concern about patient harm and abuse in a range of settings, especially hospice being an incredibly vulnerable population of people at the most difficult times in their lives. >> host: is there a federal standard for what qualifies esas a hospice -mark. >> guest: medicare does have conditions of participation for being a hospice in that program and those are the conditions that the inspectors go out and look for so when we talk about a hospice being cited for a deficiency, it's related to not meeting one of those medicare requirements . >> host: such as?

>> guest: such as taking appropriate steps to prevent infection control or quality assurance, appropriate training of hospice staff so for example, inadequate staff provision in training is one of the most common deficiencies that gets cited against hospices. this is not just a technical issue, this can have real-worldimpact on patients . we cited a case where a patient in hospice and her leg broken because her aide was not properly trained and had a safely transfer her from her wheelchair to her bed. >> and does medicare provide somesort of standard of age or at least staff within hospice and what kind of level of education or training ? >> there are standards around the qualifications and training that needs to have to provide hospice care. >> to let you know, that 1.49 million medicare beneficiaries were enrolled in hospice care for a day or more in 2017. about 64.2 percent of

patients were 80 years of age or older. most were female, 50.4 percent versus 41.6 percent male and the average length of service within hospice, 76.1 is the national hospice and palantir care organization. they respond to this report? is that the agency or at least the people that represent hospices and how do they respond -mark. >> there's a lot of attention , you are finding within the dimedia and general public as well as the hospice association so i can't speak for this particular association. but there's certainly a shared mission between our office and the race and those associations and that we're all working to try to protect patients, keep them safe and provide high-quality care. >> in general they agree with your conclusions though? >>. >> guest: i can't speak on behalf of the associations. i did see some industry opinions where they were

reinforcing the need for adequate training. transparency, and expressing concerns about the extreme example that we found. >> erin bliss with health and human services, she's the assistant inspector general for evaluation and inspection joining us to talk about the report on hospice violations. we thought with len in las vegas, independent line, go ahead. >> i was wanting to talk about healthcare for the elderly and we understand that the license, their 90 milligrams of morphine per day, per person. and she works in the elderly care and she works regularly with patients and hospice comes in and a minimum or a

maximum is 10 milligrams per hour, in other words they can give a patient on hospice 240 milligrams of lethal dose. just about everybody that gets put on hospice is dead within three days. they don't allow, she's a healthcare provider, hospice comes in, they can no longer do anything else for that epatient. they can't even give them a glass of water. >> host: okay len, thank you for calling. >> guest: certainly the use of opioids at this point is a national epidemic so it's something of great concern and the office of inspector d general has a large body of work looking at opioid misuse as well . the cdc does put out guidelines for safe dosages. those are just guidelines it is built up to the patient's

physician to determine what is the most appropriate and effective treatment given their circumstances. i willsay that when we do our analysis , taking a look at high levels of opioid use, we do exclude hospice patients from that analysis with the recognition that there are special circumstances oftentimes in hospice and the purpose of that care is to provide comfort and pain and symptom relief at the end of life. that being said no, if your wife does have specific concerns that she witnessed or worried that there might be particular hospice providers who are being irresponsible orperhaps abusive , i do encourage her to report her concerns. to the state survey agency overseas hospices. if her concerns s go all the way to the potential criminal

situation, i encourage her to reach out to local police . >> was the report that you put out, specifically name the names of those providers found in violation? >> we do not name the providers in our example. and in fact, for the 300 poor performing hospices, we identified in number, not all that information we would even be to release. so hospices who off to be inspected by private and accrediting organizations rather than the stateagencies , the results of those inspections are protected from disclosure by law. so we recommended that the medicare program works with congress to get authority to share that information as well as the resultant survey done by the states. >> clarified then, a hospice and decide to beinspected by the state or inspected by private agencies . e >> it has to be a cms

approved by the accrediting agency but that is a hospices choice. >> and would your office recommended that the state is guthe better judgment to receive on higher than that, maybe a federal inspection of the second agencies ? >> we don't have a basis to compare the quality of the inspections then done by the state agency versus the accrediting organization but the big difference that we're concerned about is that state survey results are available to the public and the results of the accrediting organization surveys are not we think that needs to change. we think it's important for all that information to be easily and readily accessible to the public. >> if there's a family receives hospice care, there wondering if there place where that care is taken in ending up in your report did they find out? >> it depends actually. on a hospice and how they wound up in our report. to hathe extent that it was based on information that was

uncovered state survey agency, that information could be made available. if it was based on information that came from and accrediting organization survey , we would not be able to release that information . and that's a problem. >> this is esther, estherin california, you're on with our guest . >> caller: icon excuse me, i'm interested in how you can govern the care of a hospice patient if you do not have the patient surrounded with governing bodies of individuals that are trained, that care, will protect their life to the end. and not speed up the expiration of life. are you eliminating suffering or are you preserving life? or there is a limitation as volunteered at?

>>. >> guest: thank you, you raise important questions about how does a medicare program, how do we oversee the quality of care provided to hospice patients who oftentimes are receiving treatment in their homes which is one of the benefits of hospice for patients who prefer to be at home you're right, it's a very vulnerable population and that's why we think the safety net around needs to be strengthened. so at this point, hospices are overseen by either a state agency that goes out and inspects them and also investigates complaints against hospices or they may opt to use an incorrect accrediting agency but in any event, they need to meet certain quality and other requirements to participate in the medicare program and then medicare has a role in overseeing the states and the hospices to make sure that system is working. >> cleveland ohio, this is

tom. >> i'd like to start off by mentioning that i recently discovered a couple months ago that the long-term care ombudsman for business, not allowed to be managed for reports of elder abuse and neglect. also they're not allowed to investigate complaints of elder abuse and neglect. that's just a starting point. i've been spending almost 30 years dealing with these kind of problems. i'd like to you talk you off the record because i can go on or hours. i'd like to connect with her. i'm an associate of a lot of different groups that are complaining about problems . one for example that's known out in california is a foundation, aiding the elderly dealing with problems at nursing homes. another is called the national association to stop elder abuse, one of the

objectives of that group is sonja arruda for faith, the organization run by carol herman, another run by doctor sam sugar is called aaa pg which stands for americans against abuse of torbay guardians. >> beforewe let you go, is there an other specific, you like to discuss with our guest ? >> health issues in the community in the lido community and others has been with what they called mildly cognitive impairedindividuals . you're talking about more than mildly cognitive impaired individuals and they are negligent of that area and disregard explicitly. >> we will let her go with that. >> iq for raising these important issues. patient abuse and neglect is a very serious concern and i a top priority for the

office of inspector general and we've done work looking at this issue across a range of settings . specific to the recently reports looking at this issue g in hospice care, we have identified all her abilities in terms of limited reporting requirements to medicare in the hospice program. so for example, hospice providers are only required to report patient harm to medicare if they receive an allegation of harm. the harm was alleged to have been involved, someone who is providing services on their behalf hospice so not necessarily a family member or a caregiver. and that the hospice as basically investigated and substantiated the allegation and only then is it required that patient harm be reported to medicare so we recommended medicare minus its reporting requirements for hospice providers as well as for rtstate surveyors to identify potential harm and abuse that might be going on when

they're out conducting their surveys. there may be laws that require reporting, but we're looking for some medicare requirements as well. so that the program has paul information's the into the problems happening and can't help ensure appropriate intervention. >> how many hospices does the report, did you look at in this report and how many compared to those at serious deficiencies? >> we look over a five-year period from 2012 to 2016. so about 4500 hospices fthat were surveyed during that time were inspected during that time. and about one in five were cited with a serious deficiency . when we look tephysically at poor performers in 2016, we identified almost one in five that either had a serious deficiency cited by a surveyor or an accrediting

organization or had a serious complaint that was in fact substantiated by the state. >> let's hear from steve in maryland, you're on with erin bliss of health and human services with the inspector general's office, go ahead. >> iq for taking my call. am i allowed to give a shout out to a specific hospice? >> go ahead with your question or comment with the guest . >> i want to mention anything, they took real good care of icmy wife and her, and it's because of the training that is done with st. mary's county and with the volunteers and with the staff. they took real good care and what i really like about this very comfortable setting, it was almost like eating in your own house. and what i really appreciated after my wife passed away, they offered grievance sessions for the spouse and that was very beneficial so i wanted to give a shout out to st. mary's county hospice

program, thank you . >> i'm sorry for your loss and i am so glad to hear about your good experience with hospice and i'm glad that you raise that because it's an important point that many patients and their loved ones have very good experiences with hospice care. we're not looking to scare anyone awayfrom hospice care, it's an important benefit . it brings great comfort to manypatients and their loved ones . we want information to be made available, not just about the problems that are found during these inspections but also information when the inspection turns up no problems. that's just as important as knowing which hospices are struggling osis knowing which hospices are performing well and we know that the vast majority of hospice providers are working very hard. they're well intended and their goal is high-quality and safe care as well . >> is his ego, he's in

maryland, identified as a president of hospice care of the organization. >> i am, this is president of the national hospice society care organization, and organization started in 1978 at the beginning of the hospice demonstrations. we represent 1200 hospices across the country. by and large we agree with muchthat's in the report . additional oversight of folks who are persistently bad, not just having a bad day but are persistently bad is a good thing. additional oversight of those is a good thing. additional education is a good thing and additional sunlight as the oig just said of the folds doing a good job and the folks who are doing a persistently bad job is a good thing. we want consumers to be informed and rmwe want people to be getting the best care that they can get, just as steve , my close associate in

maryland mentioned so that's one of the things we are here to work with the oig on is improving. >> host: did you agree with the conclusions from the report? >> caller: know, but a lot of them and certainly the themes we agreed with . we don't think that folds are complying with the law you're out and year in our providing care should be treated the same as those who are clouding it and are failing every day. so there is some room for the oversight to be tightened up and at and appropriately administered. >> would you like to oppose a question to our guest. >> we look forward, we requested a meeting with the oig, we look forward to meeting with the oig and comparing notes as we have with congress and with cns talk about how we can work together and i hope that they will jewel that meeting in short order and talk about how we can work together. >>.

>> i appreciate the work we do and we are working on scheduling the meeting. i ngwill be participating alon with some minor evaluation teams to do the work . we look forward to a fruitful partnership in protecting hospice patients and their families . >> let me ask you then if making things better is ultimate goal, what's the positive step ? a first step in your organization and yourhospices can take ? >> caller: i think a good first step is to, is sunshine. the oig has pointed out that there are 300 persistently badperformers . we want that pewas made public. a really good first step is for that list to be made public and help inform folks in making an informeddecision . >> iq, response. >> we agree. we think empowering patients and their loved ones with

access to good and clear and comprehensive information is a really crucial step. >> let's hear from anna, anna is in new york, you're on with our guest.or >> i have two very quick questions and that a brief comment. my first question is if your guests explain if there is a distinguished between what she's referencing to a state health department or cs oversight of a hospice versus what is more common in our area are reference to comfort homes. and the reason for the two batter section is because then my understanding is that if they do not come under state health department oversight. they're much more restrictive in the types of medical conditions that they can

address . of their residence in the final care. the other question i have is -- >> host: i apologize we may have to cut it because oftime and because you're cutting out . >> guest: i appreciate that question, i am not familiar with the two bed comfort homes so i will have to look into that and see what that is. if they are provider types that do participate in the medicare program, then there would be some type of conditions of participation or standards of requirement set up at that level. if they're not providers that participate in medicare, then there may be requirements of the state level if they participate in the medicaid program but i'm not familiar with that type of entity so i have to look more into that. >> host: now that the report is out, what happens as far

as follow-up? >> guest: we do persistent follow-ups with our colleagues who run the medicare program . nowhere in constant dialogue and they are making progress on the number of our recommendations . there's much more to do be done. we take the opportunity to do our findings and the two recommendations that would require some congressional intervention actually make happen, giving the medicare program more enforcement tools and allowing them to release the results of inspections inducted by accreditation organizations . are also continuing our work so we have work underway right now looking at investigations of complaints against hospices and whether the state agencies that conduct those investigations are meeting the required time frame so we will continue to push for momentum on the work we've done and the

recommendations we made as well as continue to overturn new stones and look for new issues. >> erin blister is the assistant inspector general for evaluation and inspections at health and human services. find the report they just did taking a look at hospice on their website and thank you for your time and giving us extra time with the audience . >>guest: i appreciate the opportunity to talk about these issues . >> former cia director and defense secretary robert gates, nbc correspondent andrea mitchell and journalist robin wright talk about global challenges facing the united states. here's a preview. >> i'm as much of a realist asanybody . and the reality is the united states has done business with some of history's greatest monsters. but franklin d rooseveltnever pretended to be in love with joseph stalin . and so in the real world, we

have todeal with these people . but we don't have to embrace them. and we can treat the leaders of authoritarian states. we can do business with them, but we don't need to embrace them in the same way we embrace the leaders of democraticallyelected governments . >> you mentioned the city on the hill which calls to mind when i traveled to moscow ronald reagan to meet with mikhail gorbachev after the first couple of summits, after the 1985summit and the moscow summit . and he went to the ambassador's residence and gave a speech to the russian people. the soviet then people and he did not, ronald reagan did not mince his words and that did not prevent him from reaching landmark arms-control and nuclear

reduction treaties with gorbachev. so there's a balancing act and i think values have to in some fundamental way the central to who we are as a country. >> what's the rest of this discussion on global challenges facing the us tonight at eight eastern on c-span . >> tonight on the communicators. >> people come up to me and they say i can't follow you. a naked impossible. these are people that are good at what they do. they say they make it absolutely impossible. >> we will talk about the recent presidential social media summit where president trump discussed social media censorship by big tech firms and what should be done about it with robert lewis from the

heritage foundation and patrick hedger from the competitive enterprise institute . >> as consumers we can demand that of users of facebook on twitter and google that if we're going to be on that platform we expect that they will respect our ability to mitigate. if we don't like it, we can quit. it seems hard to levy an acquisition that big tech is a net negative in any way or form when somebody like dennis prager is getting 1 billion views on the products and the videos that he's putting out. >> watch the communicators tonight at 8 pm eastern on cspan2. >> when it comes to potential for gun legislation passing through the senate and house and being signed by the president, joining us to talk about what some have to go go this way in order to make this happen is scott along with the hill, the covers capitol hill, senior staff writer. good morning to you . a story that you posted this morning on the five factors